Bhopal disaster

The Bhopal disaster (commonly referred to as Bhopal gas tragedy) was a gas leak incident in India, considered one of the world's worst industrial catastrophes.[1] It occurred on the night of December 23, 1984 at the Union Carbide India Limited (UCIL) pesticide plant in Bhopal, Madhya Pradesh, India. A leak of methyl isocyanate gas and other chemicals from the plant resulted in the exposure of hundreds of thousands of people. Estimates vary on the death toll. The official immediate death toll was 2,259 and the government of Madhya Pradesh has confirmed a total of 3,787 deaths related to the gas release.[2] Others estimate 3,000 died within weeks and another 8,000 have since died from gas-related diseases.[3][4] A government affidavit in 2006 stated the leak caused 558,125 injuries including 38,478 temporary partial and approximately 3,900 severely and permanently disabling injuries.[5] As many as 25,000 deaths have been attributed to the disaster in recent estimates.[6] UCIL was the Indian subsidiary of Union Carbide Corporation (UCC), with Indian Government controlled banks and the Indian public holding a 49.1 percent stake. In 1994, the Supreme Court of India allowed UCC to sell its 50.9 percent share. Union Carbide sold UCIL, the Bhopal plant operator, to Eveready Industries India Limited in 1994. The Bhopal plant was later sold to McLeod Russel (India) Ltd. Dow Chemical Company purchased UCC in 2001. Civil and criminal cases are pending in the United States District Court, Manhattan and the District Court of Bhopal, India, involving UCC, UCIL employees, and Warren Anderson, UCC CEO at the time of the disaster.[7][8] In June 2010, seven ex-employees, including the former UCIL chairman, were convicted in Bhopal of causing death by negligence and sentenced to two years imprisonment and a fine of about $2,000 each, the maximum punishment allowed by law. An eighth former employee was also convicted, but died before judgment was passed.
o

Summary of background
The UCIL factory was built in 1969 to produce the pesticide Sevin (UCC's brand name for carbaryl) using methyl isocyanate (MIC) as an intermediate. An MIC production plant was added in 1979 During the night of December 23, 1984, water entered a tank containing 42 tons of MIC. The resulting exothermic reaction increased the temperature inside the tank to over 200 C (392 F) and raised the pressure. The tank vented releasing toxic gases into the atmosphere. The gases were blown by northwesterly winds over Bhopal. Theories differ as to how the water entered the tank. At the time, workers were cleaning out a clogged pipe with water about 400 feet from the tank. The operators assumed that owing to bad maintenance and leaking valves, it was possible for the water to leak into the tank.[12] However,

this water entry route could not be reproduced.[13] UCC also maintains that this route was not possible, but instead alleges water was introduced directly into the tank as an act of sabotage by a disgruntled worker via a connection to a missing pressure gauge on the top of the tank. Early the next morning, a UCIL manager asked the instrument engineer to replace the gauge. UCIL's investigation team found no evidence of the necessary connection; however, the investigation was totally controlled by the government denying UCC investigators access to the tank or interviews with the operators.[14][15] The 1985 reports give a picture of what led to the disaster and how it developed, although they differ in details.[15][16][17] Factors leading to the magnitude of the gas leak include:

Storing MIC in large tanks and filling beyond recommended levels Poor maintenance after the plant ceased MIC production at the end of 1984 Failure of several safety systems (due to poor maintenance) Safety systems being switched off to save moneyincluding the MIC tank refrigeration system which could have mitigated the disaster severity

The problem was made worse by the mushrooming of slums in the vicinity of the plant, nonexistent catastrophe plans, and shortcomings in health care and socio-economic rehabilitation.[3][4][18]

Public information
initial investigation was conducted entirely by Council of Scientific and Industrial Research (CSIR) and the Central Bureau of Investigation. CSIR was forbidden to publish health effect data until after 1994. [4]

Contributing factors
Other factors identified by the inquiry included: use of a more dangerous pesticide manufacturing method, large-scale MIC storage, plant location close to a densely populated area, undersized safety devices, and the dependence on manual operations.[4] Plant management deficiencies were also identified lack of skilled operators, reduction of safety management, insufficient maintenance, and inadequate emergency action plans.[4][20] The chemical process, or "route", used in the Bhopal plant reacted methylamine with phosgene to form MIC (methyl isocyanate), which was then reacted with 1-naphthol to form the final product, carbaryl. This route differs from MIC-free routes used elsewhere, in which the same raw materials are combined in a different manufacturing order, with phosgene first reacted with naphthol to form a chloroformate ester, which is then reacted with methyl amine. In the early 1980s, the demand for pesticides had fallen, but production continued, leading to buildup of stores of unused MIC.

Work conditions

Attempts to reduce expenses affected the factory's employees and their conditions. Kurzman argues that "cuts...meant less stringent quality control and thus looser safety rules. A pipe leaked? Don't replace it, employees said they were told ... MIC workers needed more training? They could do with less. Promotions were halted, seriously affecting employee morale and driving some of the most skilled ... elsewhere".[21] Workers were forced to use English manuals, even though only a few had a grasp of the language.[12][22] By 1984, only six of the original twelve operators were still working with MIC and the number of supervisory personnel was also cut in half. No maintenance supervisor was placed on the night shift and instrument readings were taken every two hours, rather than the previous and required one-hour readings.[12][21] Workers made complaints about the cuts through their union but were ignored. One employee was fired after going on a 15-day hunger strike. 70% of the plant's employees were fined before the disaster for refusing to deviate from the proper safety regulations under pressure from management.[12][21]

Equipment and safety regulations

The MIC tank alarms had not worked for four years.[3][4][12][24] There was only one manual back-up system, compared to a four-stage system used in the United States.[3][4][12][24] The flare tower and several vent gas scrubbers had been out of service for five months before the disaster. Only one gas scrubber was operating: it could not treat such a large amount of MIC with sodium hydroxide (caustic soda), which would have brought the concentration down to a safe level.[24]. The flare tower could only handle a quarter of the gas that leaked in 1984, and moreover it was out of order at the time of the incident.[3][4][12][25] To reduce energy costs, the refrigeration system was idle. The MIC was kept at 20 degrees Celsius, not the 4.5 degrees advised by the manual.[3][4][12][24] The steam boiler, intended to clean the pipes, was out of action for unknown reasons.[3][4][12][24] Slip-blind plates that would have prevented water from pipes being cleaned from leaking into the MIC tanks through faulty valves were not installed. Their installation had been omitted from the cleaning checklist.[3][4][12] According to the operators, the MIC tank pressure gauge had been malfunctioning for roughly a week. Other tanks were used, rather than repairing the gauge. The build-up in temperature and pressure is believed to have affected the magnitude of the gas release.[3][4][12][24] UCC investigation studies have disputed this hypothesis. UCC admitted in their own investigation report that most of the safety systems were not functioning on the night of December 3, 1984.[16]

Previous warnings and incidents

A series of prior warnings and MIC-related incidents had occurred:

In 1976, the two trade unions reacted because of pollution within the plant.[4][20]

In 1981, a worker was splashed with phosgene. In panic he ripped off his mask, thus inhaling a large amount of phosgene gas; he died 72 hours later.[4][20] In January 1982, there was a phosgene leak, when 24 workers were exposed and had to be admitted to hospital. None of the workers had been ordered to wear protective masks. In February 1982, an MIC leak affected 18 workers.[4][20] In August 1982, a chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body.[4][20] UCC was warned by American experts who visited the plant after 1981 of the potential of a "runaway reaction" in the MIC storage tank. Local Indian authorities warned the company of problems on several occasions from 1979 onwards.[4][19]

The leakage
In November 1984, most of the safety systems were not functioning. Many valves and lines were in poor condition. Tank 610 contained 42 tons of MIC (disputed), much more than safety rules allowed.[4] During the nights of 23 December, a large amount of water is claimed to have entered tank 610. A runaway reaction started, which was accelerated by contaminants, high temperatures and other factors. The reaction generated a major increase in the temperature inside the tank to over 200 C (400 F). This forced the emergency venting of pressure from the MIC holding tank, releasing a large volume of toxic gases. The reaction was sped up by the presence of iron from corroding non-stainless steel pipelines.[4] Workers cleaned pipelines with water and claim they were not told to isolate the tank with a pipe slip-blind plate. Because of this, and the bad maintenance, the workers consider it possible for water to have accidentally entered the tank.[4][12] UCC maintains that a "disgruntled worker" deliberately connected a hose to a pressure gauge connection.[4][14]

Health effects
Short term health effects
The leakage caused many short term health effects in the surrounding areas. Apart from MIC, the gas cloud may have contained phosgene, hydrogen cyanide, carbon monoxide, hydrogen chloride, oxides of nitrogen, monomethyl amine (MMA) and carbon dioxide, either produced in the storage tank or in the atmosphere.[4] The gas cloud was composed mainly of materials denser than the surrounding air, stayed close to the ground and spread outwards through the surrounding community. The initial effects of exposure were coughing, vomiting, severe eye irritation and a feeling of suffocation. People awakened by these symptoms fled away from the plant. Those who ran inhaled more than those who had a vehicle to ride. Owing to their height, children and other people of shorter stature inhaled higher concentrations. Many people were trampled trying to escape.[4] Thousands of people had succumbed by the morning hours. There were mass funerals and mass cremations as well as disposal of bodies in the Narmada river. 170,000 people were treated at hospitals and temporary dispensaries. 2,000 buffalo, goats, and other animals were collected and

buried. Within a few days, leaves on trees yellowed and fell off. Supplies, including food, became scarce owing to suppliers' safety fears. Fishing was prohibited causing further supply shortages.[4] A total of 36 wards were marked by the authorities as being "gas affected", affecting a population of 520,000. Of these, 200,000 were below 15 years of age, and 3,000 were pregnant women. In 1991, 3,928 deaths had been certified. Independent organizations recorded 8,000 dead in the first days. Other estimations vary between 10,000 and 30,000. Another 100,000 to 200,000 people are estimated to have permanent injuries of different degrees.[4]

Hydrogen cyanide debate

Whether hydrogen cyanide was present in the gas mixture is still a controversy.[27][28] Exposed to high temperatures, MIC breaks down to hydrogen cyanide (HCN). According to Kulling and Lorin, at +200 C, 3% of the gas is HCN.[29] However, according to another scientific publication,[30] MIC when heated in the gas-phase starts to break down to hydrogen cyanide (HCN) and other products above 400 C. Concentrations of 300 ppm can lead to immediate collapse. The non-toxic antidote sodium thiosulfate (Na2S2O3) in intravenous injections increases the rate of conversion from cyanide to non-toxic thiocyanate. Treatment was suggested early and tentatively used on some people, but it did not provide any significative relief.[33] I

Long term health effects

It is estimated 100,000 to 200,000 people have permanent injuries. Reported symptoms are eye problems, respiratory difficulties, immune and neurological disorders, cardiac failure secondary to lung injury, female reproductive difficulties and birth defects among children born to affected women.[4]

Compensation from Union Carbide

The Government of India passed the Bhopal Gas Leak Disaster Act that gave the government rights to represent all victims in or outside India.[4] UCC offered US $350 million, the insurance sum.[4] The Government of India claimed US$ 3.3 billion from UCC.[4] In 1989, a settlement was reached under which UCC agreed to pay US$470 million (the insurance sum, plus interest) in a full and final settlement of its civil and criminal liability.[4] When UCC wanted to sell its shares in UCIL, it was directed by the Supreme Court to finance a 500-bed hospital for the medical care of the survivors. Bhopal Memorial Hospital and Research Centre (BMHRC) was inaugurated in 1998. It was obliged to give free care for survivors for eight years.[4]

Economic rehabilitation

After the incident, no one under the age of 18 was registered. The number of children exposed to the gases was at least 200,000.[4] Immediate relief was decided two days after the tragedy.[4] Relief measures commenced in 1985 when food was distributed for a short period and ration cards were distributed.[4] Widow pension of the rate of Rs 200/per month (later Rs 750) was provided.[4] One-time ex-gratia payment of Rs 1,500 to families with monthly income Rs 500 or less was decided.[4] Each claimant was to be categorised by a doctor. In court, the claimants were expected to prove "beyond reasonable doubt" that death or injury in each case was attributable to exposure. In 1992, 44 percent of the claimants still had to be medically examined.[4] From 1990 interim relief of Rs 200 was paid to everyone in the family who was born before the disaster.[4] The final compensation (including interim relief) for personal injury was for the majority Rs 25,000 (US$ 830). For death claim, the average sum paid out was Rs 62,000 (US$ 2,058).[4] Effects of interim relief were more children sent to school, more money spent on treatment, more money spent on food, improvement of housing conditions.[4] The management of registration and distribution of relief showed many shortcomings.[37] In 2007, 1,029,517 cases were registered and decided. Number of awarded cases were 574,304 and number of rejected cases 455,213. Total compensation awarded was Rs.1,546.47 crores.[38] On June 24, the Union Cabinet of the Government of India approved a Rs1265cr aid package. It will be funded by Indian taxpayers through the government.[39]

Occupational rehabilitation

33 of the 50 planned work-sheds for gas victims started. All except one was closed down by 1992.[4] 1986, the MP government invested in the Special Industrial Area Bhopal. 152 of the planned 200 work-sheds were built. In 2000, 16 were partially functioning.[4] It is estimated that 50,000 persons need alternative jobs, and that less than 100 gas victims have found regular employment under the government's scheme.[4]

Habitation rehabilitation

2,486 flats in two- and four-story buildings were constructed in the "Widows colony" outside Bhopal. The water did not reach the upper floors. It was not possible to keep cattle. Infrastructure like buses, schools, etc. were missing for at least a decade.[4]

Environmental rehabilitation

When the factory was closed in 19851986, pipes, drums and tanks were sold. The MIC and the Sevin plants are still there, as are storages of different residues. Isolation material is falling down and spreading.[4]

The area around the plant was used as a dumping area for hazardous chemicals. In 1982 tubewells in the vicinity of the UCC factory had to be abandoned.[4] UCC's laboratory tests in 1989 revealed that soil and water samples collected from near the factory and inside the plant were toxic to fish.[43] Several other studies have shown polluted soil and groundwater in the area.[4]

Union Carbide's defense

Now owned by Dow Chemical Company, Union Carbide denies allegations against it on its website dedicated to the tragedy. The corporation claims that the incident was the result of sabotage, stating that safety systems were in place and operative. It also stresses that it did all it could to alleviate human suffering following the disaster.[46]

Investigation into possible sabotage

Theories differ as to how the water entered the tank. At the time, workers were cleaning out pipes with water. The workers maintain that entry of water through the plant's piping system during the washing of lines was possible because a slip-blind was not used, the downstream bleeder lines were partially clogged, many valves were leaking, and the tank was not pressurized. The water, which was not draining properly through the bleeder valves, may have built up in the pipe, rising high enough to pour back down through another series of lines in the MIC storage tank. Once water had accumulated to a height of 6 meters (20 feet), it could drain by gravity flow back into the system. Alternatively, the water may have been routed through another standby "jumper line" that had only recently been connected to the system. Indian scientists suggested that additional water might have been introduced as a "back-flow" from the defectively designed vent-gas scrubber.[4][12] However, none of these postulated routes of entry could be duplicated when tested by the Central Bureau of Investigators (CBI) and UCIL engineers. The company cites an investigation conducted by the engineering consulting firm Arthur D. Little, which concluded that a single employee secretly and deliberately introduced a large amount of water into the MIC tank by removing a meter and connecting a water hose directly to the tank through the metering port.[14] Carbide claims such a large amount of water could not have found its way into the tank by accident, and safety systems were not designed to deal with intentional sabotage. Documents cited in the Arthur D. Little Report state that the Central Bureau of Investigation (CBI) along with UCIL engineers tried to simulate the water-washing hypothesis as a route of the entry of water into the tank. This all-important test failed to support this as a route of water entry. UCC claims the plant staff falsified numerous records to distance themselves from the incident, and that the Indian Government impeded its investigation and declined to prosecute the employee responsible, presumably because that would weaken its allegations of negligence by Union Carbide.[47]

Safety and equipment issues

The corporation denies the claim that the valves on the tank were malfunctioning, claiming that "documented evidence gathered after the incident showed that the valve close to the plant's water-washing operation was closed and leak-tight. Furthermore, process safety systemsin place and operationalwould have prevented water from entering the tank by accident". Carbide

states that the safety concerns identified in 1982 were all allayed before 1984 and "none of them had anything to do with the incident".[48] The company admits that "the safety systems in place could not have prevented a chemical reaction of this magnitude from causing a leak". According to Carbide, "in designing the plant's safety systems, a chemical reaction of this magnitude was not factored in" because "the tank's gas storage system was designed to automatically prevent such a large amount of water from being inadvertently introduced into the system" and "process safety systemsin place and operationalwould have prevented water from entering the tank by accident". Instead, they claim that "employee sabotagenot faulty design or operationwas the cause of the tragedy".[48]

Response
The company stresses the "immediate action" taken after the disaster and their continued commitment to helping the victims. On December 4, the day following the leak, Union Carbide sent material aid and several international medical experts to assist the medical facilities in Bhopal.[48] Union Carbide states on its website that it put $2 million into the Indian Prime Minister's immediate disaster relief fund on 11 December 1984.[48] The corporation established the Employees' Bhopal Relief Fund in February 1985, which raised more than $5 million for immediate relief.[49] According to Union Carbide, in August 1987, they made an additional $4.6 million in humanitarian interim relief available.[49]

Long-term fallout
Legal action against Union Carbide has dominated the aftermath of the disaster. However, other issues have also continued to develop. These include the problems of ongoing contamination, criticisms of the clean-up operation undertaken by Union Carbide.

Legal action against Union Carbide

Legal proceedings involving UCC, the United States and Indian governments, local Bhopal authorities, and the disaster victims started immediately after the catastrophe. Legal proceedings leading to the settlement On 14 December 1984, the Chairman and CEO of Union Carbide, Warren Anderson, addressed the US Congress, stressing the company's "commitment to safety" and promising to ensure that a similar incident "cannot happen again". However, the Indian Government passed the Bhopal Gas Leak Act in March 1985, allowing the Government of India to act as the legal representative for victims of the disaster,[49] leading to the beginning of legal wrangling.

In 1985, Henry Waxman, a California Democrat, called for a US government inquiry into the Bhopal disaster, which resulted in US legislation regarding the accidental release of toxic chemicals in the United States.[51] Charges against Warren Anderson and others UCC Chairman and CEO Warren Anderson was arrested and released on bail by the Madhya Pradesh Police in Bhopal on December 7, 1984. The arrest, which took place at the airport, ensured Anderson would meet no harm by the Bhopal community. Anderson was taken to UCC's house after which he was released six hours later on $2,100 bail and flown out on a government plane. In 1987, the Indian government summoned Anderson, eight other executives and two company affiliates with homicide charges to appear in Indian court.[53] Union Carbide balked, saying the company is not under Indian jurisdiction.[53] In 1991, local Bhopal authorities charged Anderson, who had retired in 1986, with manslaughter, a crime that carries a maximum penalty of 10 years in prison. He was declared a fugitive from justice by the Chief Judicial Magistrate of Bhopal on February 1, 1992, for failing to appear at the court hearings in a culpable homicide case in which he was named the chief defendant. Orders were passed to the Government of India to press for an extradition from the United States. The U.S. Supreme Court refused to hear an appeal of the decision of the lower federal courts in October 1993, meaning that victims of the Bhopal disaster could not seek damages in a US court.[49] In 2004, the Indian Supreme Court ordered the Indian government to release any remaining settlement funds to victims. In September 2006, the Welfare Commission for Bhopal Gas Victims announced that all original compensation claims and revised petitions had been "cleared".[49] In 2006, the Second Circuit Court of Appeals in New York City upheld the dismissal of remaining claims in the case of Bano v. Union Carbide Corporation. This move blocked plaintiffs' motions for class certification and claims for property damages and remediation. In the view of UCC, "the ruling reaffirms UCC's long-held positions and finally puts to restboth procedurally and substantivelythe issues raised in the class action complaint first filed against Union Carbide in 1999 by Haseena Bi and several organizations representing the residents of Bhopal". In June 2010, seven former employees of the Union Carbide subsidiary, all Indian nationals and many in their 70s, were convicted of causing death by negligence and each sentenced to two years imprisonment and fined Rs.1 lakh (US$2,124).[54] All were released on bail shortly after the verdict. The names of those convicted are: Keshub Mahindra, former non-executive chairman of Union Carbide India Limited; V.P. Gokhale, managing director; Kishore Kamdar, vicepresident; J. Mukund, works manager; S.P. Chowdhury, production manager; K.V. Shetty, plant superintendent; and S.I. Qureshi, production assistant. Federal class action litigation, Sahu v. Union Carbide et al. is presently pending on appeal before the Second Circuit Court of Appeals

in New York.[55] The litigation seeks damages for personal injury, medical monitoring[56] and injunctive relief in the form of cleanup[57] of the drinking water supplies[58] for residential areas near the Bhopal plant. A related complaint seeking similar relief for property damage claimants is stayed pending the outcome of the Sahu appeal before the federal district court in the Southern District of New York.

Ongoing contamination
Chemicals abandoned at the plant continue to leak and pollute the groundwater.[59][60][61] Whether the chemicals pose a health hazard is disputed.[62] Contamination at the site and surrounding area was not caused by the gas leakage. The area around the plant was used as a dumping ground for hazardous chemicals. By 1982 water wells in the vicinity of the UCC factory had to be abandoned. In 1991 the municipal authorities declared water from over 100 wells unfit for drinking.[4] UCC's laboratory tests in 1989 revealed that soil and water samples collected from near the factory were toxic to fish. Twenty one areas inside the plant were reported to be highly polluted. In 1994 it was reported that 21% of the factory premises were seriously contaminated with chemicals.[43][63][64] Studies made by Greenpeace and others from soil, groundwater, wellwater and vegetables from the residential areas around UCIL and from the UCIL factory area show contamination with a range of toxic heavy metals and chemical compounds.[63][64][65][66][67] Substances found, according to the reports, are naphthol, naphthalene, Sevin, tarry residues, alpha naphthol, mercury, organochlorines, chromium, copper, nickel, lead, hexachlorethane, Hexachlorobutadiene, pesticide HCH (BHC), volatile organic compounds and halo-organics. Many of these contaminants were also found in breast milk. In 2002, an inquiry found a number of toxins, including mercury, lead, 1,3,5 trichlorobenzene, dichloromethane and chloroform, in nursing women's breast milk. Well water and groundwater tests conducted in the surrounding areas in 1999 showed mercury levels to be at "20,000 and 6 million times" higher than expected levels; heavy metals and organochlorines were present in the soil. Chemicals that have been linked to various forms of cancer were also discovered, as well as trichloroethylene, known to impair fetal development, at 50 times above safety limits specified by the United States Environmental Protection Agency (EPA).[68] In a 2004 broadcast on BBC Radio 5,[69] it was reported that the site is still contaminated with 'thousands' of metric tons of toxic chemicals, including benzene hexachloride and mercury, held in open containers or loose on the ground. A drinking water sample from a well near the site had levels of contamination 500 times higher than the maximum limits recommended by the World Health Organization.[70]

In 2009, the Centre for Science and Environment (CSE), a Delhi based pollution monitoring lab, released test results showing pesticide groundwater contamination up to three kilometers from the factory. [71] The BBC took a water sample from a frequently used hand pump, located just north of the plant. The sample, tested in UK, was found to contain 1000 times the World Health Organization's recommended maximum amount of carbon tetrachloride, a carcinogenic toxin.[72] UCC states that "after the incident, UCIL began clean-up work at the site under the direction of Indian central and state government authorities", which was continued after 1994 by the successor to UCIL, Eveready Industries, until 1998, when it was placed under the authority of the Madhya Pradesh Government.[49] The successor, Eveready Industries India, Limited (EIIL), ended its 99-year lease in 1998 and turned over control of the site to the state government of Madhya Pradesh.[46]

Settlement fund hoax

On December 3, 2004, the twentieth anniversary of the disaster, a man claiming to be a Dow representative named Jude Finisterra was interviewed on BBC World News. He claimed that the company had agreed to clean up the site and compensate those harmed in the incident, by liquidating Union Carbide for $12 billion USD.[73] Immediately afterward, Dow's share price fell 4.2% in 23 minutes, for a loss of $2 billion in market value. Dow quickly issued a statement saying that they had no employee by that name that he was an impostor, not affiliated with Dow, and that his claims were a hoax. The BBC broadcast a correction and an apology.[74] "Jude Finisterra" was actually Andy Bichlbaum, a member of the activist prankster group The Yes Men. In 2002, The Yes Men issued a fake press release explaining why Dow refused to take responsibility for the disaster and started up a website, at "DowEthics.com", designed to look like the real Dow website, but with what they felt was a more accurate cast on the events.[75]